What is the management of adynamic (also known as paralytic) ileus?

From the Guidelines

Management of adynamic ileus should focus on a multifaceted approach, including minimally invasive surgery, optimized fluid management, opioid-sparing analgesia, early mobilization, early postoperative food intake, laxative administration, and omission or early removal of nasogastric intubation, as recommended by the most recent guidelines 1.

Key Components of Management

• Optimized fluid management: Efforts should be taken to correct fluid status early, aiming to have weight gain limited to < 3 kg at postoperative day three, to prevent fluid overload and minimize the risk of postoperative ileus 1.
• Opioid-sparing analgesia: The use of non-opioid analgesics is recommended when possible, as opioids can worsen ileus, and alternative pain management strategies such as epidural analgesia should be considered 1.
• Early mobilization: Patients should be assisted to mobilize as soon as possible after surgery to stimulate bowel motility and prevent complications 1.
• Early postoperative food intake: Early oral intake should be encouraged to maintain intestinal function, and small portions should be offered initially, especially after right-sided resections and small-bowel anastomosis 1.
• Laxative administration: The use of laxatives, such as bisacodyl, may be beneficial in promoting postoperative bowel function 1.
• Omission or early removal of nasogastric intubation: Nasogastric tube use should be considered on an individual basis, and daily revaluation of the need for NGI should occur, with removal as early as possible 1.

Additional Considerations

• Electrolyte abnormalities: Correction of electrolyte abnormalities, particularly hypokalemia and hypomagnesemia, is crucial to prevent worsening of ileus.
• Underlying cause: Identification and treatment of the underlying cause of ileus, such as infection, electrolyte disturbances, or medication effects, is essential for effective management.
• Prokinetic medications: The use of prokinetic medications, such as metoclopramide or erythromycin, may be considered in refractory cases, but their effectiveness is limited 1.
• Alvimopan: Alvimopan, a μ-opioid receptor antagonist, may be used post-operatively to counteract opioid-induced ileus, but its use should be guided by individual patient needs and response 1.

From the Research

Management of Adynamic Ileus

The management of adynamic (also known as paralytic) ileus involves addressing the underlying cause and providing supportive care.

• The main mechanisms of postoperative ileus pathophysiology include fluid overload, exogenous opioids, neurohormonal dysfunction, gastrointestinal stretch, and inflammation 2.
• Multiple medical interventions have been proposed, but their effectiveness is uncertain.

Medical Interventions

Several studies have investigated the effectiveness of various medical interventions in managing adynamic ileus:

• Metoclopramide has been shown to have a negative effect on the resolution of postoperative adynamic ileus, causing a delay in the time from operation to the first passage of flatus 3.
• Erythromycin has been found to have no significant effect on the resolution of ileus 2, 4.
• Early enteral nutrition (EEN) has been strongly recommended to expedite the resolution of ileus in patients who have undergone abdominal surgery 2.
• Epidural anesthesia, specifically lidocaine, has been shown to hasten the recovery of gastrointestinal motility in rats after a period of bowel ischemia 5.
• Alvimopan, a novel peripheral mu receptor antagonist, has shown potential in accelerating postoperative recovery, but more evidence is needed 4.
• Intravenous lidocaine and neostigmine may also have a potential effect, but further trials are needed to confirm this 4.

Recommendations

Based on the available evidence:

• EEN is strongly recommended to expedite the resolution of ileus in patients who have undergone abdominal surgery 2.
• Metoclopramide and erythromycin are not recommended due to lack of evidence or absence of effect 2, 3, 4.
• Further trials are needed to investigate the potential benefits of Alvimopan, intravenous lidocaine, and neostigmine 4.